Provider Demographics
NPI:1609367556
Name:BROADAWAY, LORI (BA, CD(DONA), LCCE)
Entity Type:Individual
Prefix:
First Name:LORI
Middle Name:
Last Name:BROADAWAY
Suffix:
Gender:F
Credentials:BA, CD(DONA), LCCE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4312 SHILOH TRCE
Mailing Address - Street 2:
Mailing Address - City:VALDOSTA
Mailing Address - State:GA
Mailing Address - Zip Code:31602-2393
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4312 SHILOH TRCE
Practice Address - Street 2:
Practice Address - City:VALDOSTA
Practice Address - State:GA
Practice Address - Zip Code:31602-2393
Practice Address - Country:US
Practice Address - Phone:229-300-7929
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-27
Last Update Date:2018-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes374J00000XNursing Service Related ProvidersDoula
No174H00000XOther Service ProvidersHealth EducatorGroup - Multi-Specialty